Components for the highest quality geriatric care:
Studies show that heightened focus on care during a patient’s transition to and from a healthcare setting can improve outcomes. Interventions include solid communication between acute and post-acute care providers, attention to medication reconciliation and optimization, and timely follow-up on laboratory investigations and specialist appointments. Our Care Hub care paths include a structured focus on transitional care at admission and at the time of discharge.
Advance Care Planning (ACP) provides residents, patients and families the opportunity to discuss their perspectives about goals of care. This is one of the most important activities to attain person-centeredness and to assure that patient wishes are honored, particularly at the end of life. The Care Hub care paths include a periodic focus on ACP by practitioners at the time of transitions and as needed.
Medication appropriateness and deprescribing to reduce medication burden or harm while improving quality of life
Care Hub care paths include a focus on periodic medication reviews, appropriate deprescribing and education of patients and families about their medications. Our dashboards track the deprescribing of medications every month, which improves health outcomes, saves nursing time, and minimizes iatrogenic harm.
Care Hub care paths promote proactive follow up visits and an incremental approach to review the status of various chronic comorbidities among patients and residents. A visit resulting from a fall or a fever is not the right time to address chronic issues. It is crucial that the patient and family are comfortably focused on their chronic illnesses to provide input into care planning for these issues. Care Hub risk-assessments set the frequency of these visits, so that incremental attention to chronic issues can be provided.
High quality outcomes need staff that are knowledgeable and have the proper skills to care for specific issues among frail patients. Another essential element is to keep residents, patients and their families informed about their diseases so that they are able to engage in their own care. Care Hub care paths include a focus on regular interdisciplinary grand-rounding processes to improve staff and patient/family knowledge and engagement.